RECORD OF PROCEEDINGS
PHYSICAL DISABILITY BOARD OF REVIEW

NAME:  XXXXXXXXXXXXXXXXXX	CASE:  PD-2014-02225
BRANCH OF SERVICE:  Army 	
DATE PLACED ON TDRL:  19990709	
DATE REMOVED FROM TDRL:  20021223

SUMMARY OF CASE:  Data extracted from the available evidence of record reflects that this covered individual (CI) was an active duty E3, Food Service Specialist, medically separated from the Temporary Disability Retired List (TDRL) for “schizophrenia, paranoid type,” with a disability rating of 10%.

CI CONTENTION:  The CI requests consideration of all conditions.  The CI’s complete submission is at Exhibit A.  

SCOPE OF REVIEW:  The Board’s scope of review is defined in DoDI 6040.44.  It is limited to those conditions determined by the Physical Evaluation Board (PEB) to be unfitting for continued military service and when specifically requested by the CI, those conditions identified by the PEB, but determined to be not unfitting.  Any conditions outside the Board’s defined scope of review and any contention not requested in this application may remain eligible for future consideration by the Board for Correction of Military Records.  Furthermore, the Board’s authority is limited to assessing the fairness and accuracy of PEB rating determinations and recommending corrections, where appropriate.  The Board’s assessment of the PEB rating determinations is based upon a review of medical records and all available evidence for application of the Veterans Affairs Schedule for Rating Disabilities (VASRD) standards to the unfitting medical condition at the time of separation.  The Board has neither the role nor the authority to compensate for post-separation progression or complications of service-connected conditions.  That role and authority is granted by Congress to the Department of Veterans Affairs, operating under a different set of laws.  The Board gives consideration to VA evidence, particularly within 12 months of separation, but only to the extent that it reasonably reflects the severity of the disability at the time of separation.

RATING COMPARISON:  

SERVICE PEB – 19990526/20021121	VARD - 20000531	
Condition	Code	Rating	Condition	Code	Rating
Proximate	
		TDRL
Placement	TDRL Removal			TDRL
Placement	TDRL
Removal	
Schizophrenia, Paranoid Type	9203	50%	10%	Schizophrenia, Paranoid Type	9203	70%	100%	
COMBINED RATING:  50% → 10%	COMBINED RATING OF ALL VA CONDITIONS:  70%/100%	

ANALYSIS SUMMARY:  

Schizophrenia.  According to service treatment records (STR) and the Medical Evaluation Board (MEB) mental health (MH) narrative summary (NARSUM), in February 1999, the CI was taken to the emergency room (ER) after he exhibited bizarre behavior.  Before he could be transferred to the military hospital, the CI left the hospital and got into a fight.  He was found wandering the streets with erratic and raged behavior.  His family returned him to the local hospital where he was evaluated and transferred to a psychiatric facility.  On 10 February 1999, the CI was admitted with a diagnosis of schizophreniform disorder.  At the time of admission, he reportedly had loose association and was incoherent.  He had paranoid thoughts that others talked about him and his behavior was bizarre and explosive.  He expressed delusional thinking.  During hospitalization, he required specific staff intervention to address his inappropriate behavior, and was prescribed several medications to stabilize his mood and psychotic symptoms.  

Approximately 6 weeks after admission, the CI was considered stable enough to return to duty and was discharged with medication.  However, he was readmitted 2 days later with the history that he had stopped taking his medications and had destabilized.  He was again challenged with medication, stabilized, and within 2 weeks, he was discharged as required under the law.  There was concern that he would not comply with medication since he had a history of poor compliance.  The CI was re-admitted 3 days after discharge (11 APR 99) after he was arrested by local police.  The CI reportedly had consumed cannabis products and engaged in a physical altercation with the police.

The MH NARSUM was accomplished while the CI was hospitalized, 11 April 1999.  The CI was prescribed medication and was slowing improving; however, he required multiple doses of medication to address acute threatening and bizarre behaviors.  His mental status examination (MSE) on admission documented that he was fairly cooperative, but lethargic with decreased psychomotor activity.  The CI reported his mood as “confused”, and his affect was flat.  He was sleepy, but oriented, although he lacked insight regarding hospitalization.  He denied psychotic symptoms, and his thought processes were intact, but his judgment was poor.  A brain CT scan was negative, and the physical/neurological examinations were unremarkable.  The examiner indicated that the CI would likely require transfer to a VA hospital while pending finalization of the MEB.  The diagnosis of schizophreniform disorder without good prognostic features was recorded, and a Global Assessment of Functioning (GAF) score of 42 (serious symptoms and or impairment) was documented.  The psychiatrist opined that the CI’s condition had caused occupational and social impairment with reduced reliability and productivity.  On 9 July 1999, the CI was placed on the TDRL.

The VA Compensation and Pension (C&P) mental examination was accomplished in May 2000, approximately 10 months post-TDRL placement.  The examiner noted that the CI was transferred to the VA hospital in June 1999, at the time of the PEB adjudication. It was noted that he was discharged from the inpatient with the diagnoses of schizophreniform disorder and alcohol and cannabis abuse.  He was assigned a GAF score of 80 (if symptoms are present, they are transient and expectable reactions to psychosocial stressors) at discharge.  The CI was not working, and had lived with his mother since his discharge from the hospital in July 1999.  The CI reported he had plans to live with his brother in another State and seek employment and treatment there.  He noted that he had not followed up with treatment after his hospital discharge and that he was hospitalized multiple times since July.  His last hospitalization was in April 2000.  At the time of the C&P examination, the CI noted he had recently started taking psychotropic medication and found them helpful.  He had no social life.  The CI acknowledged poor compliance in the past but now believed the only way to stay out of the hospital was to take his medications.  He had not complied in the past because he did not believe he had a problem, and during the interview he reportedly indicated he still did not believe he “really has a problem.”  The CI reported his medication helped with his sleep.  He reported depressive symptoms including suicidal ideation and noted that was the reason for his April 2000 hospitalization.  He denied auditory hallucination but admitted to visual hallucination which he believed were ghosts of “God and the devil fighting over him again.”  The CI also reported a history of 2 arrests since TDRL placement, both apparently related to disturbances in bars.  The CI was assessed with schizophrenia, paranoid type and assigned a GAF of 50 (serious symptoms and or impairment).  The examiner noted that he was “at least marginally competent at this time.”  His MSE noted psychotic content of thought.
 
At the first TDRL removal examination, approximately 13 months post-TDRL placement, the examiner noted that the CI was currently incarcerated for trespassing at a cemetery, and was escorted by the police to the examination.  He had been unable to find employment and had been unable to maintain any significant relationships outside of his parents.  The CI noted that he had been compliant with his medications but continued to have intermittent auditory and visual hallucination, some command hallucination.  He denied the use of any illicit drugs but admitted to occasional alcohol use.  The CI was continued on the TDRL.

The second TDRL examination was accomplished in October 2001, more than 2 years after TDRL placement.  The CI noted that he had been compliant with his medication and he no longer had command hallucinations.  He remained with paranoid ideations, and had recently gotten into a physical altercation with another person in the streets but did not recall what precipitated the fight.  He had not been hospitalized since 2000.  He was still unemployed and remained unable to maintain any significant relationship outside of that with his mother and his childhood friend.  The MSE noted he was somewhat disheveled in appearance, had a flattened affect and displayed some evidence of flight of ideas and loosening of associations.  His judgment was poor to fair.  The CI was continued on the TDRL.

The TDRL removal examination was conducted on 4 November 2002, approximately 2 months prior to permanent separation.  The CI indicated that he had been fairly compliant with his medication but noted that during periods of noncompliance he experiences exacerbation of paranoia and command auditory hallucination symptoms.  He had not been hospitalized since the 2001 TDRL examination.  He noted that his relationship with his mother had improved, they argued less and he had moved out of the house.  He had not been arrested since the last TDRL examination, but had not been able to find employment.  He indicated he believed his problem with employment was due to others having knowledge of his psychiatric condition.  The MSE was unremarkable with the exception of a mildly blunted affect, poor judgment due to continued use of alcohol while on medications, and recurrent failure to maintain long-term compliance.  The diagnosis of schizophrenia paranoid type was recorded with a GAF of 55 for moderate symptoms and or impairment.  The psychiatrist wrote, “Despite continued treatment and follow up, this service member has not shown any significant improvement.  Due to service members continued alcohol use and intermittent non-compliance with medication it is highly unlikely that there will be any further improvement in his condition and recurring intermittent relapses are expected to continue.”  It was noted that the CI had not used any illicit drugs since the 2001 TDRL examination.

The Board directed attention to its recommendations based on the above evidence; and, first considered whether the provisions of VASRD §4.129 for any “mental disorder that develops in service as a result of a highly stressful event” were applicable to this case (as mandated by DoD).  The Board first unanimously agreed that VASRD §4.129 was not applicable in this case, but that placement on TDRL for stabilization was appropriate.  The CI continued to have symptoms and was still in need of further stabilization.  At the time of TDRL placement, the PEB rated the condition of schizophreniform disorder coded analogously 9299-9210 at 50%.  The VA granted a 70% disability rating under the 9203 code for schizophrenia, paranoid type.

All members agreed that at the time of placement of the TDRL, the VASRD §4.130 threshold for a 50% rating was met.  However, given the multiple hospitalizations, and the fact that the CI was hospitalized at the time of the start of the MEB through TDRL placement (April-July 1999), Board members agreed his condition best reflected the 70% disability level, for “Occupational and social impairment with deficits in most areas (judgment, family relations, thinking).  Each time the CI was discharged from the hospital he quickly destabilized and require another admission.  The commander’s performance statement dated 23 April 1999, stated, “Soldier is not capable of working in the DFAC or living in the barracks.  He must be on medication and detained or he will become aggressive and uncontrollable.”  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a 70% disability rating at TDRL placement.

The Board next directed attention to the permanent rating recommendation based on the evidence described at TDRL removal.  The PEB rated the condition at 10%; however, cited that the condition of schizophrenia was adjudicated IAW DODI 1332.39 para 6.1.3 “which provides for a reduced rating when there is evidence of failure to comply with prescribed treatment.”  The PEB did not document the disability rating considered prior to the reduction.  The Board acknowledged the PEB’s application of DoDI 1332.39 in this case of medication non-compliance; however, the Board is obliged to comply with DoDI 6040.44 and the VASRD.  The VA does not make deductions based on compliance/non-compliance.  Having concluded that no deduction should be applied, members turned to deliberation of a fair rating (IAW VASRD §4.130) of the overall psychiatric disability in evidence at separation.  

The CI continued to suffer auditory hallucinations and delusions of paranoia.  He had not been hospitalized nor was there evidence of emergency care; however, he remained isolative, was unemployed, and was considered to have poor judgment, and had mild impairment in thinking.  The CI demonstrated very little improvement; however, no longer experienced command hallucinations to hurt self or others.  His symptoms had stabilized but were chronic.  He had reached maximum benefit, and the psychiatrist opined that he would have a relapsing pattern.  Due to his condition, he was unable to obtain employment.  The Board also considered the involuntary commitment to psychiatric hospital, 4 months after TDRL removal.  The record showed that the CI had not taken his medication, became psychotic, and had abused illicit drugs at the time of the admission.  He was hospitalized for 2 months.  The record demonstrated that he had difficulty in adapting to stressful environment, and remained socially isolated and was not employed,, and this was likely due to the severity of his illness; however, Board members agreed, there was insufficient evidence to support a 70% rating, and therefore, the Board agreed the condition at TDRL removal supported the 50% level of disability for “Occupational and social impairment with reduced reliability and productivity.  After due deliberation, considering all of the evidence and mindful of VASRD §4.3 (reasonable doubt), the Board recommends a disability rating of 50%, coded 9203 for the paranoid schizophrenia condition.  

BOARD FINDINGS:  In the matter of the paranoid schizophrenia condition, the Board majority recommends a disability rating of 70%, coded 9203 for the TDRL interval and a permanent disability rating of 50%, coded 9203 IAW VASRD §4.130.  There were no other conditions within the Board’s scope of review for consideration.  The Board recommends that the CI’s prior determination be modified as follows; and, that the discharge with severance pay be re-characterized to reflect permanent disability retirement, effective as of the date of his prior medical separation:  

CONDITION	VASRD CODE	RATING	
		TDRL	PERMANENT	
Paranoid Schizophrenia	9203	70%	50%	

The following documentary evidence was considered:

Exhibit A.  DD Form 294, dated 20140514, w/atchs
Exhibit B.  Service Treatment Record
Exhibit C.  Department of Veterans Affairs Treatment Record
 SAMR-RB												

MEMORANDUM FOR Commander, US Army Physical Disability Agency 
(AHRC-DO), 2900 Crystal Drive, Suite 300, Arlington, VA  22202-3557

SUBJECT:  Department of Defense Physical Disability Board of Review Recommendation for XXXXXXXXXXXXXXXXXX, AR20160016551 (PD201402225)

1.  Under the authority of Title 10, United States Code, section 1554(a), I approve the enclosed recommendation of the Department of Defense Physical Disability Board of Review (DoD PDBR) pertaining to the individual named in the subject line above to  constructively place the individual on the Temporary Disability Retired List (TDRL) at 
70% rather than 50% disability rating for the period 9 July 1999 to 22 December 2002 and then following this period recharaterize the individual’s separation as a permanent disability retirement with the combined disability rating of 50%.

2.  I direct that all the Department of the Army records of the individual concerned be corrected accordingly no later than 120 days from the date of this memorandum:

	a.  Providing a correction to the individual’s separation document showing that the individual was separated by reason of temporary disability effective the date of the original medical separation for disability with severance pay.

	b.  Providing orders showing that the individual was retired with permanent disability effective the day following the TDRL period.

	c.  Adjusting pay and allowances accordingly.  Pay and allowance adjustment will account for recoupment of severance pay, provide 70% retired pay for the constructive temporary disability retired period effective the date of the individual’s original medical separation and then payment of permanent disability retired pay at 50% effective the day following the constructive TDRL period.  

	d.  Affording the individual the opportunity to elect Survivor Benefit Plan (SBP) and medical TRICARE retiree options.

3.  I request that a copy of the corrections and any related correspondence be provided to the individual concerned, counsel (if any), any Members of Congress who have shown interest, and to the Army Review Boards Agency with a copy of this memorandum without enclosures.

BY ORDER OF THE SECRETARY OF THE ARMY:

CF: 
(  ) DoD PDBR
(  ) DVA